btw, will this be a small claims court case or not? i believe in CA if it’s under $5k or so, it can be a small claims case, which is cheaper to put together…
On 8-31-06 I went downtown to the Pretrial Conciliation meeting. It lasted about 2 minutes. The judge said that we were there to try to reach a settlement so as to avoid a formal trial. He said that Insurance was offering me nothing, so he assumed that I would not accept this and that trial would be held. I definitely was not expecting that; I thought they would start at $1000.
We were both asked if we had any motions. They said no. I just sat there looking dumbfounded. Then he asked us a question that had a word that sounded like 'lemonay' in it. Our responses were as before. I was too embarrassed to say that I didn't know what he was talking about. He said that sometimes these settlement discussions can go on for hours, but since they were offering me nothing, basically there is nothing to be said.
Why couldn't this have been done over the phone or by mail? I had to pay another parking fee so that I could be told in person that the trial is going to be held. I'm not wild about having to go downtown either.
So anyway, yesterday (9-1-06) I received this huge letter from So, So, and So LLC. It's their pretrial statement. In it, they give a time line of what has taken place starting with the Gyn's letter dated 9-3-04. They give their definition of what is 'medically necessary', saying that "a determination of medical necessity must be documented in writing, and be based on medical information provided by the Member, the Member's family/caretaker and the Member's Primary Care Practitioner."
They make reference to the OB/Gyn's letter dated 1-14-05, saying: "Dr. [Gyn] stated that the excessive hair growth , along with acne, [i]can[/i] result in ingrown hairs which in turn [i]can[/i] result in infected hair follicles. However, neither Dr.[Gyn] nor Ms. [Hir-Fem] submitted any information from a dermatologist verifying that Ms. [Hir-Fem] had ever, in fact, suffered from acne which could have exacerbated her condition."
Why doesn't the fact that an OB/Gyn said that I have acne verify this? He [u]is[/u] a doctor. Since I used to be on Retin-A, I called up my insurance plan to see if they had ever paid for this drug. They said that I have been a member since '99, but that their prescription records only go back to '03. I'm sure that I was still using Retin-a in '98, but I don't know exactly when I quit. I'm going to go to my pharmacy to see if they have kept records from back then. If they don't, I'm sure I can get proof from some other source.
Insurance's statement also says: "In total, Dr. [Gyn] has submitted two letters to [Insurance] regarding the requested electrolysis. Neither letter indicates any medical problems that Ms.[Hir-Fem] has with respect to hirsutism. Dr. [Gyn]'s first letter, dated September 3, 2004, does not indicate any medical concerns that Ms. [Hir-Fem] has with respect to her hirsutism and, in point of fact, indicates that oral contraceptives and/or spironolacotne [sic] "may be attempted in the future." Aside from the potential for in-grown hairs referenced in Dr. [Gyn]'s second letter, dated January 14, 2005, no other medical concerns are raised. In fact, Dr. [Gyn]'s second letter primarily highlights the emotional aspects of this condition. The emotional aspects have been Ms. [Hir-Fem]'s primary argument in support of electrolysis as well, as evidenced by a letter that she submitted to [Insurance] dated February 23, 2005."
First of all, the Gyn wrote three letters, the first being dated 6-4-04. I can prove they received it because they make reference to it in their first denial letter dated 8-11-04. I also have the registered mail receipt.
I can't stand that they keep twisting their definition of medical necessity. It states that a service will be covered if it will improve the effects of an illness. The illness is PCOS (and Insulin Resistance), and the effects are the hairs. [u]They[/u] try to say that hirsutism is the illness, which they feel has no effects. I'm so angry and frustrated that I could scream.
They mentioned in their time line that I won the first two hearings. I like to see that in writing, especially when Insurance is the one writing it.
Then they give a list of exhibits. Under that they have the lawyer's signature. It's dated 8-30-06. If that's when they filed it, then they missed their 8-7-06 deadline.
My concern is: was it [u]mandatory[/u] for me to file a pretrial statement? My deadline was 7-24-06. Have I ruined everything?Here are my trial highlights, which may not be in order, and are definitely not complete:
9-22-06 Trial Day: There were four or five people on the defendant’s side. I was alone. Contrary to what I’m used to, the lawyer introduced herself to me, shook my hand, and told me not to be nervous. Usually they avoid even making eye contact. She gave me another copy of their exhibits. I handed her mine and said “Here’s my stuff.” (Real professional.)
My List of Exhibits:
A: 6-2-04 Prescription for electrolysis from the Gynecologist
B: Certified mail receipt, signed and dated 6-6-04
C: 8-11-04 letter from insurance requesting more info
D: 8-26-04 letter from insurance denying coverage
E: 9-3-04 letter of medical necessity from Gyn
F: Photo of beard, 7-9-04
G: 1-14-05 letter of medical necessity from Gyn
H: PCP’s prescription for electrolysis and Depo-Provera; proof of Metformin coverage
I: Electrolysis receipts
I also provided a statement as follows:
"I have been diagnosed with Polycystic Ovary Syndrome (PCOS) and Insulin Resistance. Both of these conditions cause Hirsutism, which is a male hair pattern on a woman.
“[Insurance]'s Definition of Medical Necessity states that they will cover a service or benefit that “will, or is reasonably expected to, reduce or ameliorate the physical, mental, or developmental effects of an illness, condition, injury, or disability.””
"My conditions are PCOS and Insulin Resistance. Their physical effect is Hirsutism.
"[Insurance] has denied coverage on the basis that the Hirsutism itself is not the cause of any medical problems.
"[Insurance] has approved coverage of the drug Metformin ER to treat my Insulin Resistance. They are also covering the hormonal injection Depo-Provera, which is being used to halt further spread of the Hirsutism.
“According to [Insurance’s] pretrial statement, page 5, they claim to have received two letters from Dr. [Gyn]. However, I have two letters from [Insurance] acknowledging receipt of Dr. [Gyn]'s first letter, which is dated June 2, 2004. Along with this I have a Certified Mail Receipt as proof that this was delivered to them.”
After their lawyer read this, she went back to her team. I heard a lot of whispering.
A man who worked for the judge came up to me and asked if there was anything in the defendant’s pretrial statement that I don’t agree with. He told me to highlight those parts, so I underlined the bit about their only having two letters from the Gyn, and the parts where they had determined that electrolysis was not medically necessary. Everyone was then provided with a copy of what I had highlighted.
Before the judge came out, we were told some rules: The judge likes a clean record, so no talking over each other, and especially no interrupting the judge; this really p***es him off. [His words.] Also, no fighting amongst ourselves; whatever we have to say has to be said to the judge when he asks for it.
The judge, (who looked like Will Ferrell, if you’re near-sighted), asked us for an opening statement. Insurance gave their schpeel. All I said was that I felt that the statement I submitted with my list of exhibits says it all. At some point he asked me if I rest my case, and I was like ‘duh’. Even though I’ve heard of that before, I was afraid to answer. I thought that if I said ‘yes’ I wouldn’t be allowed to speak again, but I ended up saying ‘yes’ anyway. In my opinion, I did a horrible job this time. I was inept and mousy. I even said ‘yeah’ instead of ‘yes’ once. I called the judge ‘sir’, (I just can’t see myself calling a judge ‘your honor’; I’d feel goofy).
He went over the points I objected to in Insurance’s pretrial statement. Insurance said that they didn’t have the Gyn’s 1st letter in their files.
They called a doctor, (who works for them), to the stand as a witness. He said that Hirsutism is a male pattern of hair on a woman, yet he called it a ‘natural variant’, a common cosmetic condition, saying that 10% of women have it. [What’s so natural about a woman with a beard? Back in the days of freak sideshows, did they hire people with ‘natural variants’? No, they hired people with abnormalities- like lizard skin, conjoined twins, or bearded ladies. Also, isn’t cancer common? Isn’t heart disease common? Do they only cover rare maladies? I didn’t say any of this, though.] He likened what I’m going through to not feeling tall enough or pretty enough.
Both the doctor and the lawyer said that they can sympathize with what I’m going through.
The lawyer went through the list of their exhibits with the doctor. Then I was asked if I had any questions for him. “Why does Insurance cover acne, since it is common and cosmetic?”, I asked. The doctor paused, then said that the line between what is cosmetic and what is medically necessary is gray. [So is my chin.] Acne can also lead to infection. was an infection.]
Either the judge or the lawyer asked the doctor if having a prescription for something proves that it is medically necessary. He said ‘no’. [When I had a consultation with a lawyer, he had said the same thing. I was hoping that he was wrong. He also said that if I win I won’t necessarily set a precedent, because other people’s cases can differ from mine.]
Insurance gave their closing argument, restating their schpeel. They mentioned that I could treat my beard with bleaching or shaving. [Just what I want, a stiff blond beard. And shaving is not the answer; I want the beard gone. Again, I didn’t say any of this out loud.] When I was asked for my final statement, I again said that my written statement says it all, and I’d like the judge to keep in mind that I have already won two hearings. The judge told me that he’s not allowed to know that; his decision can’t be swayed by anyone else’s. [Then why did the defense say in their pretrial narrative that I had won twice? Shouldn’t they know better? Besides, it makes them look bad.]
I wish I would have taken notes during the defense’s speeches. They went on so long that when the judge asked me if I disagreed with anything that had been said, I couldn’t remember anything. I was too busy being intensely focused on being respectful and not acting like the people on TV court shows who loose their cool and can’t control their behavior.
After it was over I realized that I should have had a opening and closing statement. At the time, I felt that being repetitious would insult the judge’s intelligence. But maybe lawyers repeat themselves so much because they feel that if a person hears something often enough, they will start to believe it.
I managed not to cry this time. Maybe I’m getting used to this. I did shake a little, though.
Some days later I received a letter from the judge:
“AND NOW, this 25th day of September, 2006, after a non-jury trial before the undersigned, it is hereby found that the electrolysis treatment undergone by the plaintiff was not a “medical necessity” as defined in the [Insurance] Physical Health Agreement and 55 Pa. Code § 1141.2. Said treatment is a noncompensable service under 55 Pa. Code § 1141.59 and plaintiff is not entitled to reimbursement for the cost of the electrolysis. Award is entered in favor of defendant.”
55 Pa. Code § 1141.2 gives the definition of cosmetic surgery as: “A surgical procedure the primary purpose of which is to improve the appearance of the patient. The procedures include, but are not limited to, otoplasty for protruding ears or lop ears, rhinoplasty, except to correct internal nasal deformity, nasal reconstruction, excision of keloids, fascioplasty, osteoplasty for prognathism or micrognathism or both, dermabrasion, skin grafts and lipectomy.”
55 Pa. Code § 1141.59 is a list of noncompensable services. Point (1) says that they will not pay for “Procedures not listed in the Medical Assistance program fee schedule.” Point (13) says they will not pay for “Cosmetic surgery as defined in § 1141.2. Exception: Cosmetic surgery is a covered service when performed in order to improve the functioning of a malformed body member, to correct a visible disfigurement which would affect the ability of the person to obtain or hold employment, or as postmastectomy breast reconstruction.”
I’m very sorry to all of you who helped me do this or were hoping that I could set a precedent to help you in your case. I really wanted to help all of us.
I wish I knew a lawyer in your area.
All the exceptions listed in the first code statment are for things that are efforts to revert a person BACK to pre medical issue condition. No one is born with Keloids, they form and appear at some point, and usually don’t go away any time soon, if ever at all. This is no different from your condition, other than the most likely practitioner attending to the problem, and therefore billing the insurance company is not a doctor.
The argument for electrolysis in your case is not based on the medical need for removal of hair to look better, although their line about correcting something that MIGHT impede someone from getting or sustaining employment opens up an appeal as well, after all, from models, to receptionists and on down to waitresses, one might lose a job due to appearance. Your condition leads to an unmaskable appearance flaw that unfairly limits your earning potential.
The argument that is usually used is that the promise the insurance company has broken is to pay for treatment that would restore you, as best can be done, to your pre-medical-issue-condition. PCOS causes hair to grow, as can diabetes, as can many medications.
You honestly are the first person I know of who sued and lost on this issue of coverage. Of course, it could be a lot like the USFL vs NFL anti-trust case. The defendants spent so much time proving the crime of anti-trust, they neglected to put forth a convincing argument for the amount of damages they sustained. Another recent case, the Obese Teens vs McDonalds the judge dismissed the case, but said that the defendants should resubmit the case with a better explaination of the actual case, as they failed in his opinion to present a comprehensive case for exactly how great the McDonald’s customers conception of the nutritional value of McDonald’s product differs from the dangers of actually consuming the products and the difference between the demonstrated side effects of use of these products and the expectation one purchasing the products has. McDonalds took the time they had to resubmit and used it to get a law passed making it illegal to sue them on these grounds.
You can’t get a new stop light, you can’t pass a law that helps the general public in any reasonable time, but bills like this seem to be on the exlax road to law passage. <img src="/ubbthreads/images/graemlins/mad.gif" alt="" />
I hope you can explore some avenues to get justice for yourself. I hope someone reading this can offer you some help AND ACTUALLY STEPS UP TO DO SO.
Has anybody EVER got a insurance company to pay for electrolysis? And that is on a female, I’m a male so I’m pretty sure they’d be like what it’s not a big deal. I work at a insurance company and the thought of them even remotely thinking about paying for something like this is almost laughable.
I have, and many other electrologists have clients whose insurance companies ARE paying for their treatment. The only thing that varies is how much of a fight they put up before paying, and how they chose to make the payments. Some pay the practitoner directly, some pay the prescribing doctor and have him pay the electrologist, and others make the client pay and submit for re-imbursements. I have even had insurance payments made to me directly from companies for transgendered persons having treatment. <img src="/ubbthreads/images/graemlins/shocked.gif" alt="" /> Of course, most companies made the insured pay me up front and reimbursed the client on a periodic basis after verification of treatment.
I would be so bold as to say that any insurance company that has been around for ten years or more HAS paid for electrolysis for more than one client. They just don’t want the flood gates to open and have every lady who qualifies to show up tomorrow looking for treatment on their dime. This is especially true in a culture where the food supply is polluted with things that actually cause hair growth in a shockingly large number of women. Too much money is made peddling the poisons, and since the usual suspects don’t make money “curing” the women of the unwanted hair, they fight compensation.
Think about it, what is the difference between the rational in paying for Vaniqua and paying for Electrolysis. The only difference is WHO one is paying. To clear a script for Vaniqua, one is offering to pay for that drug for the life of the insured, should they maintain coverage. Electrolysis during one year would be less money in total. Other than the fact that the average person ceases to utilize Vaniqua due to dissatisfaction with the results, and/or the dosage schedule, and/or side effects and therefore doesn’t end up taking it for life, there would be no cost savings.
The law firm that I fought against sent me a seven page letter telling me that I lost. Part of it is called a “NOTICE OF ENTRY OF JUDGMENT”, and states: “Please take notice that judgment against the plaintiff and in favor of the defendant has been entered in the Court of Common Pleas of Allegheny County, Pennsylvania at the above number on this 12[th] day of October, 2006.” Another part is called “PRAECIPE FOR ENTRY OF JUDGMENT ON DECISION IN NON-JURY TRIAL”. It states: “Please enter judgment in favor of the defendant and against the plaintiff in accordance with the attached decision of the Court dated September 25, 2006, rendered following a trial without a jury, no timely post-trial motions having been filed.”
Why do they have to file that they won? Isn’t it already on record? I have already received a letter from the judge and one from the Court telling me I lost.
On Friday, Oct. 20, I finally got around to calling the Prothonotary to ask about appealing. They told me that I had to write it up and have it filed by Monday. When I asked what I was supposed to write, they said that I have to hire a lawyer for that. They suggested I call Neighborhood Legal Services. They told me that they don’t do that (which is what they said before in June '05). I called the Allegheny County Bar Association Center for Volunteer Legal Resources. They said it would cost me $25 (just like before) for a half hour consultation plus the lawyer’s fees, and it would take them a couple of days to get back to me. So I said ‘forget it’.
Looks like my procrastination has ruined everything. All the money, time, effort, and emotion that I spent on this was all for nothing.
Law is so complicated so that everyone knows that they just should hire a lawyer.
There are even some deadlines that don’t apply if you have a lawyer representing you.